As part of the inspection an unannounced visit was undertaken by eight compliance inspectors on 18th July 2012. On this day we looked at four areas of the trust: care of the elderly services (in ward T7), cancer and haematology services (in the University College Hospital MacMillan Cancer Centre and wards T13N, T16N, and T14N), maternity services (in the Elizabeth Garrett Anderson wing), and the emergency care pathway for patients (in the A&E and the acute medical unit). We conducted an additional visit, on 24th July 2012, to meet staff in the trust’s complaints and governance teams. In addition, we assessed all the data and information we hold on the trust.

Overall, we spoke with 48 patients or their relatives and to 50 members of staff from a range of medical, nursing, and therapy backgrounds.

In general, the patients we spoke to were very positive about the experiences they had had at the trust. Most told us they felt the staff were very supportive and treated them with respect. They felt they had control over decisions about their care and that there were enough staff to meet their care needs. They also told us that they felt they were involved in their care and that staff usually took time to explain what they were doing.

Patients told us they thought the hospital was clean and that they had seen regular cleaning taking place.

The following are examples of comments we received from patients:

“Very nice hospital. People and nurses are very nice.”

“Nurses have been wonderful.”

“Very happy with service.”

“The staff are very friendly and approachable.”

“Staff take the time to explain what’s happening.”

“Lovely midwives, very caring.”

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We spoke to people using the services and staff in each of the areas that we visited. People who use the service generally felt that they were looked after well and that staff were attentive and caring. Overall people stated that the level of cleanliness was very good and that the wards are swept and cleaned on a regular basis. People have seen that beds and equipment are cleaned between uses. Most people said that hand cleaning is carried out by staff in advance of any care being provided.

At the Elizabeth Garret Anderson (EGA) we visited the theatres, the birthing centre, labour ward, neonatal ward, post natal and antenatal wards. People told us that they felt well looked-after throughout their pregnancies and had been treated as individuals, with dignity and respect. They told us staff were available to explain, reassure and assist when needed. All the people we spoke to told us that they felt safe and well-looked after.

People told us that they were treated well and that staff were polite and kept them informed. They told us that the food was good and that there were enough staff on duty to meet their needs.

Most patients seemed well informed about their care and treatment at the hospital. Relatives and carers also said the staff were respectful and always willing to explain their care treatment plan in a well mannered and respectful way.

Some patients and relatives informed us that while the staff were very polite, their requests were not being acted upon as quickly as they would have liked and that more familiarity between the staff and patients would be beneficial.

We have received patient comments which includes the following extracts, "the staff always inform you about your treatment and keep you up to date", and some patients said that the staff were polite and respectful and others felt that they were treated with dignity and respect throughout their stay.

Some patients in the orthopaedic ward we visited were full of praise for the treatment they were receiving and the explanations given to them by staff, however one patient did point out the fact that in the curtained patient bays, even with the curtains drawn, conversations could be heard and information given to one patient could be easily heard by other patients.

Most of the patients we spoke with said that the food was good and that there was a good range of choices. We observed the food and found it to be warm and well presented on the day of the inspection. A patient who was bed-bound was helped with the choice of food and sitting position to eat the food. Most of the relatives we spoke to about the nutritional aspect of their relatives care also gave us positive feedback about the food. They told us that the food was good and presented very well and that patients seemed to be enjoying the meals.

We noted that the menu has a wide variety of choice and takes into account religious and cultural sensitivities of the population the hospital served.

Our general observations were that staff assisted patients with lunch and that all the food was eaten completely by all the patients we saw. Lunch was described by all the patients we spoke to as very good and delicious. Protected mealtimes were in action and we observed patients being left alone to eat and others who were unable to feed themselves were being helped to eat their food as well.

Our rating of services went down. We rated the hospital as requires improvement because:

• We rated safe and responsive at this hospital as requires improvement and we rated effective, caring, and well-led as good.
• Although the trust had made many improvements to the hospital’s emergency department, we found a number of areas that still required improvement. Similar to the previous CQC inspection, we found that patient documentation was not consistently completed and that the department performed poorly against the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge.
• Patients with mental health needs often experienced delays within the ED and best practice guidelines for care and treatment of these patients were not consistently followed. At the time of this inspection, there was no parallel assessment of a patient’s physical and mental health needs. The trust was in process of reviewing its service level agreement with the third party provider of the psychiatric liaison service and was working with the provider to identify and address problems with service delivery.
• Mandatory training compliance rates for medical staff fell below the trust target.
• The trust performed worse than the 85% operational standard for patients receiving their first cancer treatment within 62 days of an urgent GP referral.
• Midwifery staffing levels were low in relation to the acuity of women. Women did not always received one-to-one care in established labour. The trust recognised that this had a negative impact on staff morale and patient experience and we saw there were plans in place to address this. Staffing levels were regularly reviewed and staff were redeployed within the maternity unit when needed to keep patients safe.
• We observed a number of lapses in good infection prevention and control measures including some staff not following trust procedures for bare below the elbow, use of personal protective equipment or disposal of infectious material. The cleanliness of the environment and equipment in some areas presented an infection control risk.
• We found that actions from risk assessments were not always implemented. For example, concerns around use of surveillance cameras within the endoscopy unit were not addressed effectively and some of the divisional leaders were not aware of the use of these cameras within the unit. We were concerned that staff process flow was prioritised over patients’ privacy and dignity. After this had been pointed out to the trust they withdrew the use of the screen while they reviewed their practice in this area.
• There was a backlog of GP and discharge letters in the IT system and there were delays for non-urgent letters being sent out via the new electronic systems. This was on the trust risk register, and an action plan was in place to resolve the issue.
• Patients found it hard to contact the trust via telephone to discuss their appointment, with many calls going unanswered.
• Emergency equipment was not always stored securely and checked daily. We found two ward areas where resuscitation equipment was not secure and could be accessed by unauthorised persons.
• Whilst we saw many examples of good practice in relation to medicines management, the trust’s policies for safe storage and management of medicines were not always followed consistently.

However:

• We rated all services inspected at this hospital as good, other than urgent and emergency services (ED).
• The trust had made several improvements to the emergency department to provide a better and safer patient experience including improving consultant cover and how effectively the department managed sepsis.
• Leadership within the ED and medical care services had improved.
• The hospital had systematic and established systems in place for reporting, investigating and acting on incidents and serious adverse events. There was an open culture of reporting, and learning was shared with staff to make improvements.
• There were effective arrangements in place to safeguard patients from abuse and mitigate the risk of it happening.
• The service made sure staff were competent for their roles. Staff were encouraged to undertake continuous professional development, so the trust was ensured staff were competent for their roles and were able to provide an effective service.

• Staff followed national professional standards and guidelines to achieve the best possible outcomes for patients receiving care and treatment. There was an effective process and system in place to ensure guidelines and policies were updated and reflected national guidance and improvement in practice. Audits and quality outcomes were conducted at departmental level to monitor the effectiveness of care and treatment.
• Different groups of staff worked together as a team to benefit patients. Medical staff, nurses, midwives and allied health professionals supported each other and worked collaboratively to ensure patient centred and effective care.
• Patients and their families were treated and cared for with compassion, patience and respect. Feedback from patients about their experience of care was consistently positive. We observed staff listening to patients and discussing aspects of their care.
• Services were planned and provided in a way that met and supported the needs of local people, including those with complex or additional needs. The trust worked closely with the commissioners, clinical networks, patients and other stakeholders to plan the delivery of care and treatment.
• There was a positive and friendly culture. We observed good team working amongst staff of all levels. Staff told us that they were proud to work for the hospital and were well supported by their colleagues.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Leaders were knowledgeable about service performance, priorities, as well as challenges and risks.
• There was a strong culture of improvement, research and innovation. There was a commitment to improving services by learning both when things went well and when they went wrong. Safe innovation and team success was celebrated.